Safety and Efficacy of Reperfusion Therapies for Acute Ischemic Stroke Patients with Active Malignancy
Introduction
Active malignancy (AM: i.e. malignant cancer, metastasis, current chemo, or radiotherapy) is a well-known risk factor for ischemic stroke.1 Cancer-related hypercoagulability has been shown to be the most likely factor leading to this cascade.2 AM and ischemic stroke are associated to an increased risk of short-term mortality compared to stroke without AM.3 For this reason, stroke physicians often face with the ethical matter of managing such patients in the acute phase of ischemic stroke when intravenous thrombolysis (IVT) and/or, mechanical thrombectomy (MT), or combined IVT and MT (IVMT) must be considered and information about details regarding AM should be obtained. Safety concerns could increase uncertainty, making clinical decision even more challenging. Small series investigating the effects of IVT in patients with acute ischemic stroke (AIS) and AM have shown poor efficacy and safety outcomes with high rate of hemorrhagic transformation.4 Despite benefit exceeds costs deriving from the worldwide spread of MT, previous studies have not included patients with chronic diseases affecting life-expectancy.5, 6
Our aim was to test the efficacy and safety of reperfusion strategies (IVT, MT, and IVMT) among AIS patients with AM.
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Material and Methods
We performed a retrospective matched cohort study using our prospective local stroke treatment registry between January 2011 and March 2018. Each AM patient with AIS was individually matched to a cancer-free control patient with AIS by the following variables: age, sex, cardiovascular risk factors (hypertension, diabetes, atrial fibrillation, smoking), glycemia, and blood pressure (systolic and diastolic), prestroke modified Rankin Scale (mRS), clinical severity measured by National Institute
Results
Out of 1243 patients undergoing one of the above mentioned reperfusion strategies, 24 AM patients with AIS in the anterior circulation were found and matched with a control group of 24 AIS patients without history of cancer treated with one of the above mentioned reperfusion therapies. Clinical characteristics of AM group are shown in Table 1. In this group, 41.6% of patients had advanced malignancy (stage IV) and the most frequent type of cancer was lung, followed by colorectal, breast and
Discussion
AM may affect short-term survival and represents a challenging ethical matter for stroke physicians. In these patients AIS treatment could result in therapeutic obstinacy if neurological improvement cannot overwhelm quickly worsening of cancer disease. On the other side decision for no AIS treatment could result in a shortening of life-expectancy.
Few studies have investigated outcomes of cancer-related stroke patients after reperfusion strategies. In one of these recanalization after
Conclusions
Our study suggest that reperfusion strategies such as IVT, MT, and IVMT are safe and effective for AIS patients with AM but an individualized screening for life-expectancy seems warranted (Table 4).
Acknowledgments: We thank all stroke neurologists at the comprehensive stroke center of university of Tor Vergata (Angela Giordano MD, Vittoria Carla D'Agostino PhD, Marta Panella MD, Barbara Rizzato PhD, Simone Napolitano MD, Domenico Samà PhD, Francesco Mori, MD) for collection of data.
Authorship Conformation
All authors have participated in (a) conception and design, or analysis and interpretation of the data; (b) drafting the article or revising it critically for important intellectual content; and (c) approval of the final version.
This manuscript has not been submitted to, nor is under review at, another journal or other publishing venue.
Conflict of Interest
The authors have no affiliation with any organization with a direct or indirect financial interest in the subject matter discussed in the manuscript.
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Financial Disclosure: This work was supported by a grant of the Italian Ministry of Health (RF-2013-02358679) to F.S. and G.K.